05000255/FIN-2012003-03
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Finding | |
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Title | Failure to Follow Work Management Process for Reactor Head Work |
Description | The inspectors identified a finding of very low safety significance with an associated NCV of Technical Specification (TS) 5.4.1, Procedures, for the failure to properly follow the work management process for work done to loosen stuck reactor head studs. During the April-May 2012 refueling outage, difficulty was encountered in loosening some of the reactor head studs to support refueling operations. The decision was made to retension the studs that had already been detensioned (without ascending back to Mode 5 from Mode 6) and start over using a more precise electric pumping unit that had not been used to that point due to equipment issues. Contrary to EN-WM-102, Work Implementation and Closeout, the licensee used the field change process, not authorized for this type of change, to pen-and-ink different tensioning values and sequence in the normal tensioning procedure (so as not to return to Mode 5). Additionally, the inspectors identified that the steps documented as having been performed as a record of the contingency actions taken differed from what was actually performed. The licensee entered the issue into the CAP as Condition Reports CR-PLP-2012-2610 and CR-PLP-2012-2848, and corrected the contingency work instructions. The issue was determined to be more than minor because if left uncorrected, it could lead to more significant safety issues. Specifically, the failure to follow appropriate processes and correctly document reactor head work is indicative of shortfalls that could occur for other safety-related work. Additionally, the licensee was slow to recognize the issue. The inspectors concluded that the Initiating Events Cornerstone was impacted because of the potential for an inadvertent mode change. The finding screened as Green, or very low safety significance, using IMC 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination Process, based on all of the mitigation criteria being met and no phase 2 or 3 analysis being required per Checklist 3, indicating there was no impact to shutdown safety functions. The inspectors determined that the finding had an associated cross-cutting aspect in the area of human performance in that personnel work practices did not support human performance. Specifically, supervisory and management oversight failed to assure the proper processes were followed |
Site: | Palisades ![]() |
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Report | IR 05000255/2012003 Section 1R20 |
Date counted | Jun 30, 2012 (2012Q2) |
Type: | NCV: Green |
cornerstone | Initiating Events |
Identified by: | NRC identified |
Inspection Procedure: | IP 71111.2 |
Inspectors (proximate) | M Holmberg J Cassidy T Bilik M Mitchell J Geissner D Jones J Ellegood T Taylor A Scarbeary W Lyon S Shah D Alley |
CCA | H.2, Field Presence |
INPO aspect | LA.2 |
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Finding - Palisades - IR 05000255/2012003 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Palisades) @ 2012Q2
Self-Identified List (Palisades)
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